Spinal Cord (2000) 38, 435 ± 441 ã 2000 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/00 $15.00 www.nature.com/sc Deltoid triceps transfer and functional independence of people with tetraplegia AL Dunkerley*,1, A Ashburn1 and EL Stack1 1University Rehabilitation Research Unit, University of Southampton, UK Study design: Matched case control study. Setting: Two regional spinal units ± Salisbury, UK (surgical centre) and London, UK (control centre). Objective: To compare the functional independence and wheelchair mobility of spinal cord injured subjects, post deltoid triceps transfer, with matched control subjects. Methods: Two matched groups of subjects, with tetraplegia resulting in triceps paralysis, were studied. The surgical group consisted of ®ve of the six patients who had previously undergone deltoid triceps transfer at Salisbury. The control group (n=6) had not undergone surgical intervention but were comparable with respect to level of lesion, age, age at injury and duration of disability. All subjects completed standardised assessments of activities of daily living (Functional Independence Measure ± FIM) and wheelchair mobility (10 m push and ®gure of 8 push). Surgical subjects completed additional questions, regarding the perceived eects of surgery on function. Results: It was not possible to demonstrate absolute functional dierences with the chosen outcome measures in this small series of matched case controls. All surgical subjects cited speci®c functional improvements since surgery and recommended the procedure. However the FIM lacked sucient sensitivity to detect these changes. Conclusion: Further investigation of the functional outcome of deltoid triceps transfer in tetraplegia is warranted. Development of more sensitive outcome measures would be useful. Spinal Cord (2000) 38, 435 ± 441. Keywords: tetraplegia; deltoid triceps transfer; functional independence; spinal cord injury Introduction Upper limb paralysis, following cervical spinal cord individuals studied had normal shoulder power, elbow injury (SCI) presents diculties in activities of daily ¯exion and wrist extension. In addition, the second living (ADL) e.g. dressing and washing. In some cases, group, with functional triceps, had normal or near individuals can learn to modify their motor behaviour normal elbow extension. Results showed that a greater to best suit their physical capacities1 and so realise proportion of subjects with triceps control were further functional abilities: in particular, wheelchair independent in activities such as dressing and bed propulsion, self feeding and sometimes, turning in bed, mobility. transfers and driving with hand controls.2 Patients A tetraplegic person with a paralysed triceps muscle themselves regard improved upper limb function as a has reduced upper extremity strength and stability.5 top priority in relation to other aspects of their There are diculties in positioning and stabilising the disability.3 Following a study of 29 tetraplegics, Welch arm as a result. Although gravity may assist elbow et al4 concluded that voluntary control of triceps was a extension, it may also cause it to buckle, allowing the signi®cant determinant in the ability to perform self hand to suddenly strike the face or forehead. Tendon care tasks. These authors studied two groups ± those transfer has the potential to replace the action of with wrist extensors as the lowest functioning muscle paralysed muscle. The main principles of surgery have and those with triceps as the lowest functioning muscle. been outlined elsewhere.6,7 The deltoid triceps transfer, In all cases muscle power was sucient to produce pioneered over 20 years ago,8 is considered useful in movement against gravity with some resistance. All individuals with SCI at the level of C5 and C6 where there is absent or limited elbow extension.9±11 The posterior portion of the deltoid muscle is used to replace the action of triceps in elbow extension. *Correspondence: A Dunkerley, C/o University of Southampton Posterior deltoid is detached from its insertion and Rehabilitation Research Unit, Level E (886), Centre Block, re-joined to the triceps aponeurosis using either a free Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK tendon or arti®cial graft. Deltoid triceps transfer AL Dunkerley et al 436 Surgical restoration of active elbow extension in between the levels of C4 ± 6. At the time of the study patients with cervical SCI is thought bene®cial in six patients had undergone simple deltoid triceps increasing functional ability but has been poorly surgery. Control subjects were recruited from the evaluated. Improved reach and stability have aided Royal National Orthopaedic Hospital, Stanmore, a personal care, such as grooming and eating.10 ± 14 Some spinal unit with similarities in the philosophy and authors have noted sucient strength to allow weight practice of rehabilitation. The aim was to match each shifts to relieve pressure,5,9,10,13,14 although it has not surgical subject, by the following variables, to two been observed as particularly useful in improving controls where possible: subjects' ability to transfer. Elbow extension may assist in getting into a sitting position, turning in bed . Level of injury and residual motor and sensory and also bracing the body in the event of falling function according to the International Classifica- forward in a wheelchair.8,14 Improvements in recrea- tion24 tional, educational and social functioning as well as . Age within 5 years employment opportunities are dicult to quantify. Time since injury (as closely as possible within age However, facilitation of driving, swimming and writing band) have been reported.10 ± 12,14,15 . Gender The diculties in assessing the outcome of upper limb surgery have been highlighted.8,9,16,17 Moberg11 The same exclusion criteria used to identify patients stated that an improvement in control not power, is for surgery were applied to control subjects. Also essential in evaluating the eect of deltoid triceps excluded were those unable to propel a manual transfer. However, outcomes are commonly demon- wheelchair as they would be unable to complete part strated by power measured on strain gauges, torques of the assessment. For practical reasons, subjects were produced in muscle contraction and range of elbow UK residents and spoke English. Ethical approval was extension. There is a relative dearth of research granted at both centres. Informed consent to take part focusing on measurable functional gains. Methods of was given by each subject. patient evaluation vary throughout the literature making comparison of ®ndings from dierent re- searchers dicult. Improvements in wheelchair con- Outcome measures trol and mobility have been reported5,9,13,14,18,19 yet it An adapted Functional Independence Measure appears that objective testing was not used to support (FIM)22 was used to quantify the performance of these observations. Functional independence has been activities of daily living. The scoring system accounts assessed by interview or questionnaire in some studies for the use of adaptive equipment and various levels of and by locally devised ADL scales in others.13,20 Few assistance likely to be encountered in a tetraplegic studies17,21 have used existing measures such as the group. Reliability and validity of this scale have been Functional Independence Measure (FIM).22 established22,25 and it has been endorsed by the American Spinal Injuries Assocation (ASIA) as a standard measure of function in SCI. Good clinical Objective interrater agreement has been reported.26 The con- The aims of the study were to describe and compare ventionally scored FIM, using clinician observation to the functional capacity of a group of people with assign scores, was not practical in the present study. A tetraplegia with and without deltoid triceps transfer self reporting version of the FIM, developed and found surgery. No previous studies have compared operated to be reliable in a pilot study,23 was devised as an and non-operated subjects with the same diagnosis. alternative. It was scored according to the subject's The hypothesis was: people with tetraplegia who have description of ability. Self reporting has been undergone deltoid triceps transfer surgery have greater documented elsewhere 24,27 ± 30 with substantial agree- functional independence than a matched non-interven- ment between clinician and patient rated scores. The tion control group. This paper reports some of the complete FIM consists of 18 items grouped in six results from a larger study investigating upper limb sections and scored on a seven level scale (where 1 tendon transfer surgery in tetraplegia.23 indicates total dependence and 7 indicates total independence). The sections of communication and social cognition were not deemed relevant in the Method context of this study and were omitted. Subjects were scored on a total of 13 items under four headings: self Subjects care, sphincter control, mobility and locomotion. A group of subjects who had undergone deltoid triceps Two further methods of objective measurement of transfer at the Duke of Cornwall Spinal Treatment wheelchair propulsion were used to augment the scores Centre, Salisbury were compared with a group of non- from the FIM locomotion section: the 10 m push and surgical (control) subjects in a matched case-control the ®gure of 8 push. Each subject completed the tests study. All subjects had sustained a traumatic SCI in his own manual wheelchair. It was assumed that resulting in non-progressive motor complete tetraplegia chairs were set up optimally for the users. Both tests Spinal Cord Deltoid triceps transfer AL Dunkerley et al 437 were conducted on a hard, smooth and level ¯oor. collection had been completed. These four subjects Subjects were instructed to traverse each course as fast were not assessed. No reasons were given by those who as possible. The 10 m push was considered the declined to participate. equivalent of the 10 m walk31 in ambulant and able- Six control subjects were assessed. It was therefore bodied subjects. It was measured over a straight course not possible to match two to each surgical subject as of 16 m.